Chapter Information
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Chapter/University Name:
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Mailing Address:
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City:
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State:
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Zip Code:
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Office Phone Number:
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Fax:
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E-mail:
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Web Address:
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Chapter Advisor's First Name:
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Chapter Advisor's Last Name:
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Chapter Advisor's ASHA Account Number:
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Chapter Advisor's E-mail:
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Co-Advisor's First Name:
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Co-Advisor's Last Name:
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Co-Advisor's ASHA Account Number:
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Co-Advisor's E-mail:
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Chapter President's First Name:
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Chapter President's Last Name:
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Chapter President's NSSLHA Account Number:
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Chapter President's E-mail:
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Chapter Vice-President's First Name:
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Chapter Vice-President's Last Name:
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Chapter Vice-President's NSSLHA Account Number:
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Chapter Vice-President's E-mail:
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Region Number (locate your region):*
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Application
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Timeframe to Consider This Application:*
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Has this Chapter received this grant in the past?*
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If received in past, indicate semester and year received.
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If awarded, the check should be made payable to:*
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Name of Community Organization Designated to Receive Support:*
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Date Funds are Needed:*
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Provide a clear and concise description of why the local chapter selected the organization to support and how the grant will benefit the organization.*
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Describe the equipment or materials that you will purchase with these monies. Be specific (include make and model of equipment, title and publisher of clinic materials, etc.).*
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When and where will the organization be presented with your donation (in the event this application is funded)?*
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| Who is the contact person at the organization your chapter wants to support? |
First Name:
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Last Name:
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Title:
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Mailing Address:
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City:
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State:
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Zip Code:
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Phone Number:
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E-mail:
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Web Address:
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List all previous projects carried out by this NSSLHA Chapter (if no previous projects have been completed, type "none"):*
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| Funding for Community Service grants is awarded as a matching funds grant. This means that NSSLHA will match funds raised by the local chapter up to $1,000. |
Amount of Support to be Provided by Your Local NSSLHA Chapter:
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Matching Funds You are Requesting From the NSSLHA National Office:
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Total of the Two Amounts Listed Above:
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Please describe how the local chapter raised (or will raise) the matching funds for the grant award.
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